Village Survey 🔍

Before You Begin

Welcome to The Village of Care! This short survey helps you reflect on your current wellness, stability, and overall life capital — the personal, social, and emotional strengths that support your growth.

Please answer each question honestly based on your current experiences and needs. There are no right or wrong answers — your responses simply help identify areas where The Village can offer support, tools, or coaching.

Full Name *

Phone

Email *

Are you a parent? *

What is your age? (Write number only) *

Postal Code

Example: 32303

Gender *

Male

Female

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How often do you worry about being able to meet normal monthly living expenses? *

0= Worry All of the Time (I think about how bills will get paid )10= Do Not Ever Worry (I do not worry about paying any of my bills)

How would you rate your overall mental health? *

0= Poor (I have more Negative thoughts than good thoughts during the day)10= Excellent (I have more Good thoughts than negative thoughts during the day)

How often do you worry about safety? *

0= Worry All the Time (I worry everyday about my safety conditions) 10= Do Not Ever Worry (I do not worry at all about my safety)

How often do you worry about having food? *

0= Worry All the Time (I worry everyday about food) 10= Do Not Ever Worry (I do not worry at all about food)

How often do you worry about your housing? *

0= Worry All the Time (I worry everyday about my living conditions) 10= Do Not Ever Worry (I do not worry at all about my living conditions)